A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess for neck vein distention
Monitor for postural hypotension
Assess blood glucose level
Monitor for an irregular heart rate
Weigh the client daily
Correct Answer : A,C,D,E
A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.
B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.
C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.
D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.
E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Have an eye examination once per year." Annual eye examinations are essential for detecting diabetic retinopathy early. Early detection and treatment can help prevent vision loss. This is a key recommendation for managing diabetes-related eye complications.
B. "Examine your feet carefully every day." While daily foot examinations are important for preventing diabetic foot ulcers and other complications, they do not directly address the prevention of retinopathy and nephropathy, which are more related to blood glucose control and vascular health.
C. "Wear compression stockings daily." Compression stockings are used to manage conditions like chronic venous insufficiency and to prevent deep vein thrombosis, but they are not related to the prevention of diabetic retinopathy or nephropathy.
D. "Maintain stable blood glucose levels." Keeping blood glucose levels stable is crucial for preventing both retinopathy and nephropathy. Chronic hyperglycemia is a major risk factor for these complications, and good glycemic control reduces the risk of developing or worsening these conditions. This is also crucial but does not specifically target the complications as precisely as regular eye exams do.
Correct Answer is D
Explanation
A. Serum T4: In primary hypothyroidism, serum T4 levels are usually low due to decreased production by the thyroid gland.
B. Serum T3: Serum T3 levels are also typically low in primary hypothyroidism, as the thyroid gland produces less hormone overall.
C. Free T4: Free T4, the biologically active form of T4, is also usually low in primary hypothyroidism, reflecting decreased thyroid function.
D. Thyroid stimulating hormone (TSH): In primary hypothyroidism, the thyroid gland is underactive and does not produce enough thyroid hormones (T3 and T4). As a result, the pituitary gland releases more TSH in an attempt to stimulate the thyroid to produce more hormones, leading to elevated TSH levels.
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